Provider Demographics
NPI:1538468780
Name:KOOP, KWYNN NULSEN (DDS)
Entity Type:Individual
Prefix:
First Name:KWYNN
Middle Name:NULSEN
Last Name:KOOP
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34640 N NORTH VALLEY PKWY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-3247
Mailing Address - Country:US
Mailing Address - Phone:623-879-9503
Mailing Address - Fax:
Practice Address - Street 1:34640 N NORTH VALLEY PKWY
Practice Address - Street 2:SUITE 104
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85086-3247
Practice Address - Country:US
Practice Address - Phone:623-879-9503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-26
Last Update Date:2011-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD008166122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist